Advances In The Diagnosis And Management Of Ectopc
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ADVANCES IN THE DIAGNOSIS AND MANAGEMENT OF ECTOPC PREGNANCY DR. A.B.A. ANDE MATERNO-FETAL UNIT UNIBEN / UBTH
ECTOPIC PREGNANCY DEFINITION Any pregnancy where the fertilised ovum gets implanted and develops in a site other than normal uterine cavity.
INCIDENCE > 1 in 100 pregnancies
Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries - USA – 5 fold - UK – 2 fold - France – 15/1000 - India – 1 in 100 deliveries - Nigeria – 2-3% of gynecological emergencies Recurrence rate – 15% after 1st, 25% after 2 ectopics
HISTORY
963 AD – Albucasis first described Ectopic Pregnancy 1884 -- Robert Lawson Tait of Birmingham performed the forst successful Salpingectomy operation 1953 – Stromme – Conservatice surgery of Salpingostomy 1973 – Shapiro & Adller – Laparoscopic Salpingectomy 1991 – Young et al – Laparoscopic Salpingotomy
AETIOLOGY
Any factor that causes delayed transport of the fertilised ovum through the fallopian tube favours implantation in the tubal mucosa, giving rise to a tubal ectopic pregnancy. These factors may be Congenital or Acquired.
AETIOLOGY
CONGENITAL – Tubal Hypolasia, Tortuosity, Congenital diverticuli, Accessory ostia, Partial stenosis. AQUIRED – - Inflammatory: PID, Septic Abortion, Puerperal Sepsis, MTP (Intraluminal adhesion) - Surgical: Tubal reconstructive surgery, Recanalisation of tubes - Neoplastic: Broad ligament myoma, Ovarian tumour. - Miscellaneous Causes: IUCD, Endometriosis, ART (IVF & GIFT), Previous ectopic.
SITES OF ECTOPIC PREGNANCY
1) Fimbrial 2) Ampullary 3) Isthmic 4) Interstitial 5)Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligamen 10) Primary abdominal
CLINICAL PRESENTATION
Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations – Acute and Chronic SYMPTOMS - Amenorrhea - Abdominal Pain - Syncope - Vaginal Bleeding - Pelvic Mass
DIAGNOSIS “Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it.” -- Mc. Fadyen – 1981.
DIAGNOSIS
In recent years, in spite of an increase in the incidence of ectopic pregnancy, there has been a fall in the case fatality rate. This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease. This has resulted in early diagnosis and effective treatment. Now the rate of tubal rupture is as low as 20 %.
METHODS OF EARLY DIAGNOSIS
Immunoassy utilising monoclonal antibodies to β-HCG. Ultrasound scanning – Abdominal & Vaginal including Colour Doppler Laparoscopy Serum progesterone estimation not helpful A combination of these methods have to be employed.
METHODS OF EARLY DIAGNOSIS
TVS can visualise a gestational sac as early as 4 – 5 weeks from LMP. During this time, the lowest serum β HCG is 2000 IU/L. When β HCG level is greater than this and there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected. In such a situation, when the value of β HCG does not double in 48 hours ectopic pregnancy will be confirmed.
METHODS OF EARLY DIAGNOSIS Ultrasound features of ectopic pregnancy after 5 weeks can be any of the following: 2. Demonstration of the gestational sac with or without a live embryo (Begel’s sign) – The GS appears as an intact well defined tubal ring by 6 weeks when it measures 5 mm in diameter. Afterwards it can be seen as a complete sonolucent sac with the yolk sac and the embryonic pole with or without heart activity inside.
METHODS OF EARLY DIAGNOSIS Ultrasound features of ectopic pregnancy after 5 weeks can be any of the following: 2. Poorly defined tubal ring possibly containing echogenic structure and POD contaaining fluid or blood. 3. Ruptured ectopic with fluid in the POD and an empty uterus. 4. In Colour Doppler, the vascular colour in a characteritic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow
MANAGEMENT
Depends on the stage of the disease and the condition of the patient at diagnosis. Options: - Surgery – Laparotomy / Laparoscopy - Medical – Administration of Trophotoxics at the site or systemically
MANAGEMENT OF ACUTE ECTOPIC PREGNANCY
Hospitalisation Resuscitation: - Treatment of shock - Lie flat with the leg end raised - Analgesics - Blood transfusion
MANAGEMENT OF ACUTE ECTOPIC PREGNANCY Culdocentesis: Highly specific if performed and interpreted correctly: - Presence of Free – Flowing, NON-Clotting blood Negative tap inconclusive Remains controversial.
MANAGEMENT OF ACUTE ECTOPIC PREGNANCY Laparotomy should be done at the earliest. Salpingectomy is the definitive treatment. No benefit from removing Ovary along with the tube. Blood Transfusion: Autotransfusion.
MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY INVESTIGATIONS: Laboratory/Chemical test: - Serial quantitative β HCG level by RIA - Serum Progesterone level (<5 mg/ml in ectopic pregnancy) - Low levels of Trophoblastic Proteins such as SPI and PAPP- Placental Protein 14 & 12 USS – Usually haematocele is found Laparoscopy
MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY TREATMENT – ALWAYS SURGICAL Salpingectomy of the offending tube If pelvic haematocele is infected, posterior colpotomy is to be done to drain the prelvic abcess Salpingo-oophorectomy
MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY OPTIONS: Surgical Surgically Administered Medical (SAM) treatment Medical treatment Expectant management
SURGICAL TREATMENT OF ECTOPIC PREGNANCY
Carried out either by Laparotomy / Laparoscopy The procedures are: -Salpingectomy / Cornual resection / Excision - Conservative Surgery (in cases of infertility & desire for pregnancy) • Linear salpingostomy • Linear salpingotomy • Segmental resection and anastomosis • Milking out the tube
SURGICAL TREATMENT OF ECTOPIC PREGNANCY LAPAROTOMY? VS LAPAROSCOPY? SALPINGECTOMY? VS SALPINGOSTOMY / SALPINGOTOMY
COMPARING LAPAROTOMY Vs LAPRAOSCOPY L’tomy L’scopy Hospital cost More? Less? Post operative adhesions More Less Risk of futuer ectopic Same Same Future fertility Same Same Experience of Surgeon Trained Special
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
All tubal pregnancies can be treated by partial or total Salpingectomy Salpingostomy / Salpingostomy is only indicated when: 1. 2. 3. 4. 5.
The patient desires to conserve her fertility Patient is haemodynamically stable Tubal pregnancy is accessibly Unruputed and < 5 cm in size Contra lateral tube is absent or damaged
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
The choice of surgical treatment does not influence the post treatment fertily, but prior history of infertility is associated with a marked reduction in fertility after treatment Making the choice: Chapron et al (1993) have described a scoring system, based on the patient's previous gynaecological history and the appearance of the pelvic organs, to deicde between salpingostomy / salpingotomy and salpingectomy.
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
Fertility reducing factor •
•
•
• • •
•
Score Antecedent one Ectopic pregnancy 2 Antecedent each further Ectopic pregnancy 1 Antecedent adhesiolysis 1 Antecedent Tubal micro surgery 2 Solitary tube 2 Antecedent Salpingitis 1 Homolateral Adhesions
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy. Conservative surgery is indicated with a score of less than 5, while radical treatment is to be performed if the score is 5 or more.
LAPAROSCOPIC SALPINGECTOMY
It is carried out by laparoscopic scissors and diathermy or Endo-loop. After passing a loop of No. 1 catgut over the ectopic pregnancy, the stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch. The excised tissue is removed piece meal or in a tissue removal bag.
LAPAROSCOPIC SALPINGOTOMY
To reduce blood loss, first 10 – 40 IU of Vasopressin diluted in 10 ml of normal saline is injected into the mesosalpinx. Then the tube is opened through an anitmesenteric longitudinal incision over the tubal pregnancy by a - Co2 laser (Paulson, 1992) - Argon laser (Keckstein et al; 1992) - Laparoscopic scissors snd ablating the bleeding points with bipolar diathermy. - Fine diathermy knife (Lundorff, 1992)
LAPAROSCOPIC SALPINGOTOMY The tubal pregnancy is then evacuated by suction irrigation. Hemostasis of the trophoblastic bed is ensured. The tubal incision is left open.
PERSISTENT ECTOPIC PREGNANCY (PEP)
This is a complication of salpingotomy / salpingostomy when residual trophoblastic continues to survive because of incomplete evacuation of the ectopic pregnancy. Diagnosis is made because of a raised postoperative serum β HCG If untreated, can cause life threatening hemorrhage
PERSISTENT ECTOPIC PREGNANCY (PEP)
TREATMENT is by: - Reoperation and futher evacuation / Salpingectomy - Administration of IM / oral Methotrexate in a single dose of 50 mg/m2 of body surface
SAM TREATMENT
Aim: Trophoblastic destruction but avoiding the systemic side effects Technique: Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by- laparoscopy or - Ultrasonographically guided • •
Transabdominal (Porreco, 1992) Transvaginal (Feichtinger et al, 1989)
- With Falloposcopic control (Kiss et al, 1993) - Hysteroscopic control (Goldenberg et al, 1992) - Hysterosalpingographic control (Risquez et al, 1990)
SAM TREATMENT
Trophotoxic substances used: - Methotrexate (Pansky et al, 1989) - Potassium Chloride (Robertson et al, 1987) - Mifepristone (RU 486) - PGF2α (Lindblom et al, 1987) - Hyper osmolar glucose solution (Lang et al, 1992) - Actinomycin D
MEDICAL TREATMENT WITH METHOTREXATE
Resolution of tubal preganancy by systemic administration of Methotrexate was first described by Tanaka et al (1982) Mostly used for early resolution of placental tissure in abdominal pregnancy. Can be used for tubal pregnancy as well Mechanism of action- Interferes with the DNA synthesis by inhibiting the synthesus to pyrimidines leading to trophoblasic cell death. Auto enzymes and maternal tissues then absorb the trophoblast.
MEDICAL TREATMENT WITH METHOTREXATE
Ectopic pregnancy size should be <3.5 cm. Can be given IV/IM/Oral, usually along with Folinic acid Recent concept is to give Methotrexate IM in a single dose of 50mg/m2 without Folinic acid. If serum HCG does not fall to 15% within 4 – 7 days, then a second dose of Methotrexate is given and resolution is confirmed by HCG estimation
MEDICAL TREATMENT WITH METHOTREXATE
Advantages: - Minimal hospitalisation. Usually outpatient treatment: Reduces cost. - Quick recovery - 90% success if cases are properly selected Disadvantages: - Side effects like GI & Skin - monitoring is essential- Total blood count, LFT & serum HCG once weekly till it becomes negative
EXPECTANT TREATMENT
Tubal Pregnancies are known to Abort / Resolve Before the advent of salpingectomy in 1884, ectopic pregnancies were being treated expectanly with 70% mortality. (Parry, 1876) Diagnosis made at PM! Today only selected cases are managed expectantly: screened and identified by high relolution ultrasound scanner and monitored by serial serum β HCG assay
EXPECTANT TREATMENT
Identification criteria (Ylostalo et al, 1993): - Falling level of serum β HCG at 2 day intervals - No sign of intrauterine pregnancy - Diameter of ectopic pregnancy <4 cm - No sign of rupture or of acute bleeding by TVS If any deviation from the above criteria
EXPECTANT TREATMENT
Spontaneous resolution occurs in 72%, while 28% will need laparoscopic salpingostomy In spontaneous resolution, it may take 4 – 67 days (mean 20 days) for the serum HCG to return to non pregnant level. The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2. Warning:- Tubal pregnancies have been known to rupture when when serum HCG levels are low.
SUMMARY – KEY POINTS
Incidence of ectopic pregnancy is rising while maternal mortality from it is falling. Early diagnosis is the key to less invasive treatment. The choice today is Laparoscopic treatment of unruptured ectopic pregnancy. The trend is towards conservative treatment. Careful monitoring and proper councelling of patients is mandatory. Ruptured ectopics should be unususal with compliant patients and appropriate medical care.
ECTOPIC PREGNANCY DEFINITION Any pregnancy where the fertilised ovum gets implanted and develops in a site other than normal uterine cavity.
INCIDENCE > 1 in 100 pregnancies
Recent evidence indicates that the incidence of ectopic pregnancy has been rising in many countries - USA – 5 fold - UK – 2 fold - France – 15/1000 - India – 1 in 100 deliveries - Nigeria – 2-3% of gynecological emergencies Recurrence rate – 15% after 1st, 25% after 2 ectopics
HISTORY
963 AD – Albucasis first described Ectopic Pregnancy 1884 -- Robert Lawson Tait of Birmingham performed the forst successful Salpingectomy operation 1953 – Stromme – Conservatice surgery of Salpingostomy 1973 – Shapiro & Adller – Laparoscopic Salpingectomy 1991 – Young et al – Laparoscopic Salpingotomy
AETIOLOGY
Any factor that causes delayed transport of the fertilised ovum through the fallopian tube favours implantation in the tubal mucosa, giving rise to a tubal ectopic pregnancy. These factors may be Congenital or Acquired.
AETIOLOGY
CONGENITAL – Tubal Hypolasia, Tortuosity, Congenital diverticuli, Accessory ostia, Partial stenosis. AQUIRED – - Inflammatory: PID, Septic Abortion, Puerperal Sepsis, MTP (Intraluminal adhesion) - Surgical: Tubal reconstructive surgery, Recanalisation of tubes - Neoplastic: Broad ligament myoma, Ovarian tumour. - Miscellaneous Causes: IUCD, Endometriosis, ART (IVF & GIFT), Previous ectopic.
SITES OF ECTOPIC PREGNANCY
1) Fimbrial 2) Ampullary 3) Isthmic 4) Interstitial 5)Ovarian 6) Cervical 7) Cornual-Rudimentary horn 8) Secondary abdominal 9) Broad ligamen 10) Primary abdominal
CLINICAL PRESENTATION
Ectopic Pregnancy remains asymptotic until it ruptures when it can present in two variations – Acute and Chronic SYMPTOMS - Amenorrhea - Abdominal Pain - Syncope - Vaginal Bleeding - Pelvic Mass
DIAGNOSIS “Pregnancy in the fallopian tube is a black cat on a dark night. It may make its presence felt in subtle ways and leap at you or it may slip past unobserved. Although it is difficult to distinguish from cats of other colours in darkness, illumination clearly identifies it.” -- Mc. Fadyen – 1981.
DIAGNOSIS
In recent years, in spite of an increase in the incidence of ectopic pregnancy, there has been a fall in the case fatality rate. This is due to the widespread introduction of diagnostic tests and an increased awareness of the serious nature of this disease. This has resulted in early diagnosis and effective treatment. Now the rate of tubal rupture is as low as 20 %.
METHODS OF EARLY DIAGNOSIS
Immunoassy utilising monoclonal antibodies to β-HCG. Ultrasound scanning – Abdominal & Vaginal including Colour Doppler Laparoscopy Serum progesterone estimation not helpful A combination of these methods have to be employed.
METHODS OF EARLY DIAGNOSIS
TVS can visualise a gestational sac as early as 4 – 5 weeks from LMP. During this time, the lowest serum β HCG is 2000 IU/L. When β HCG level is greater than this and there is an empty uterine cavity on TVS, ectopic pregnancy can be suspected. In such a situation, when the value of β HCG does not double in 48 hours ectopic pregnancy will be confirmed.
METHODS OF EARLY DIAGNOSIS Ultrasound features of ectopic pregnancy after 5 weeks can be any of the following: 2. Demonstration of the gestational sac with or without a live embryo (Begel’s sign) – The GS appears as an intact well defined tubal ring by 6 weeks when it measures 5 mm in diameter. Afterwards it can be seen as a complete sonolucent sac with the yolk sac and the embryonic pole with or without heart activity inside.
METHODS OF EARLY DIAGNOSIS Ultrasound features of ectopic pregnancy after 5 weeks can be any of the following: 2. Poorly defined tubal ring possibly containing echogenic structure and POD contaaining fluid or blood. 3. Ruptured ectopic with fluid in the POD and an empty uterus. 4. In Colour Doppler, the vascular colour in a characteritic placental shape, the so-called fire pattern, can be seen outside the uterine cavity while the uterine cavity is cold in respect to blood flow
MANAGEMENT
Depends on the stage of the disease and the condition of the patient at diagnosis. Options: - Surgery – Laparotomy / Laparoscopy - Medical – Administration of Trophotoxics at the site or systemically
MANAGEMENT OF ACUTE ECTOPIC PREGNANCY
Hospitalisation Resuscitation: - Treatment of shock - Lie flat with the leg end raised - Analgesics - Blood transfusion
MANAGEMENT OF ACUTE ECTOPIC PREGNANCY Culdocentesis: Highly specific if performed and interpreted correctly: - Presence of Free – Flowing, NON-Clotting blood Negative tap inconclusive Remains controversial.
MANAGEMENT OF ACUTE ECTOPIC PREGNANCY Laparotomy should be done at the earliest. Salpingectomy is the definitive treatment. No benefit from removing Ovary along with the tube. Blood Transfusion: Autotransfusion.
MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY INVESTIGATIONS: Laboratory/Chemical test: - Serial quantitative β HCG level by RIA - Serum Progesterone level (<5 mg/ml in ectopic pregnancy) - Low levels of Trophoblastic Proteins such as SPI and PAPP- Placental Protein 14 & 12 USS – Usually haematocele is found Laparoscopy
MANAGEMENT OF CHRONIC ECTOPIC PREGNANCY TREATMENT – ALWAYS SURGICAL Salpingectomy of the offending tube If pelvic haematocele is infected, posterior colpotomy is to be done to drain the prelvic abcess Salpingo-oophorectomy
MANAGEMENT OF UNRUPTURED ECTOPIC PREGNANCY OPTIONS: Surgical Surgically Administered Medical (SAM) treatment Medical treatment Expectant management
SURGICAL TREATMENT OF ECTOPIC PREGNANCY
Carried out either by Laparotomy / Laparoscopy The procedures are: -Salpingectomy / Cornual resection / Excision - Conservative Surgery (in cases of infertility & desire for pregnancy) • Linear salpingostomy • Linear salpingotomy • Segmental resection and anastomosis • Milking out the tube
SURGICAL TREATMENT OF ECTOPIC PREGNANCY LAPAROTOMY? VS LAPAROSCOPY? SALPINGECTOMY? VS SALPINGOSTOMY / SALPINGOTOMY
COMPARING LAPAROTOMY Vs LAPRAOSCOPY L’tomy L’scopy Hospital cost More? Less? Post operative adhesions More Less Risk of futuer ectopic Same Same Future fertility Same Same Experience of Surgeon Trained Special
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
All tubal pregnancies can be treated by partial or total Salpingectomy Salpingostomy / Salpingostomy is only indicated when: 1. 2. 3. 4. 5.
The patient desires to conserve her fertility Patient is haemodynamically stable Tubal pregnancy is accessibly Unruputed and < 5 cm in size Contra lateral tube is absent or damaged
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
The choice of surgical treatment does not influence the post treatment fertily, but prior history of infertility is associated with a marked reduction in fertility after treatment Making the choice: Chapron et al (1993) have described a scoring system, based on the patient's previous gynaecological history and the appearance of the pelvic organs, to deicde between salpingostomy / salpingotomy and salpingectomy.
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
Fertility reducing factor •
•
•
• • •
•
Score Antecedent one Ectopic pregnancy 2 Antecedent each further Ectopic pregnancy 1 Antecedent adhesiolysis 1 Antecedent Tubal micro surgery 2 Solitary tube 2 Antecedent Salpingitis 1 Homolateral Adhesions
SALPINGECTOMY Vs SALPINGOSTOMY/SALPINGOTO MY
The rationale behind the scoring system is to decide the risk of recurrent ectopic pregnancy. Conservative surgery is indicated with a score of less than 5, while radical treatment is to be performed if the score is 5 or more.
LAPAROSCOPIC SALPINGECTOMY
It is carried out by laparoscopic scissors and diathermy or Endo-loop. After passing a loop of No. 1 catgut over the ectopic pregnancy, the stitch is tightened and then the tubal pregnancy is cut distal to the loop stitch. The excised tissue is removed piece meal or in a tissue removal bag.
LAPAROSCOPIC SALPINGOTOMY
To reduce blood loss, first 10 – 40 IU of Vasopressin diluted in 10 ml of normal saline is injected into the mesosalpinx. Then the tube is opened through an anitmesenteric longitudinal incision over the tubal pregnancy by a - Co2 laser (Paulson, 1992) - Argon laser (Keckstein et al; 1992) - Laparoscopic scissors snd ablating the bleeding points with bipolar diathermy. - Fine diathermy knife (Lundorff, 1992)
LAPAROSCOPIC SALPINGOTOMY The tubal pregnancy is then evacuated by suction irrigation. Hemostasis of the trophoblastic bed is ensured. The tubal incision is left open.
PERSISTENT ECTOPIC PREGNANCY (PEP)
This is a complication of salpingotomy / salpingostomy when residual trophoblastic continues to survive because of incomplete evacuation of the ectopic pregnancy. Diagnosis is made because of a raised postoperative serum β HCG If untreated, can cause life threatening hemorrhage
PERSISTENT ECTOPIC PREGNANCY (PEP)
TREATMENT is by: - Reoperation and futher evacuation / Salpingectomy - Administration of IM / oral Methotrexate in a single dose of 50 mg/m2 of body surface
SAM TREATMENT
Aim: Trophoblastic destruction but avoiding the systemic side effects Technique: Injection of trophotoxic substance into the ectopic pregnancy sac or into the affected tube by- laparoscopy or - Ultrasonographically guided • •
Transabdominal (Porreco, 1992) Transvaginal (Feichtinger et al, 1989)
- With Falloposcopic control (Kiss et al, 1993) - Hysteroscopic control (Goldenberg et al, 1992) - Hysterosalpingographic control (Risquez et al, 1990)
SAM TREATMENT
Trophotoxic substances used: - Methotrexate (Pansky et al, 1989) - Potassium Chloride (Robertson et al, 1987) - Mifepristone (RU 486) - PGF2α (Lindblom et al, 1987) - Hyper osmolar glucose solution (Lang et al, 1992) - Actinomycin D
MEDICAL TREATMENT WITH METHOTREXATE
Resolution of tubal preganancy by systemic administration of Methotrexate was first described by Tanaka et al (1982) Mostly used for early resolution of placental tissure in abdominal pregnancy. Can be used for tubal pregnancy as well Mechanism of action- Interferes with the DNA synthesis by inhibiting the synthesus to pyrimidines leading to trophoblasic cell death. Auto enzymes and maternal tissues then absorb the trophoblast.
MEDICAL TREATMENT WITH METHOTREXATE
Ectopic pregnancy size should be <3.5 cm. Can be given IV/IM/Oral, usually along with Folinic acid Recent concept is to give Methotrexate IM in a single dose of 50mg/m2 without Folinic acid. If serum HCG does not fall to 15% within 4 – 7 days, then a second dose of Methotrexate is given and resolution is confirmed by HCG estimation
MEDICAL TREATMENT WITH METHOTREXATE
Advantages: - Minimal hospitalisation. Usually outpatient treatment: Reduces cost. - Quick recovery - 90% success if cases are properly selected Disadvantages: - Side effects like GI & Skin - monitoring is essential- Total blood count, LFT & serum HCG once weekly till it becomes negative
EXPECTANT TREATMENT
Tubal Pregnancies are known to Abort / Resolve Before the advent of salpingectomy in 1884, ectopic pregnancies were being treated expectanly with 70% mortality. (Parry, 1876) Diagnosis made at PM! Today only selected cases are managed expectantly: screened and identified by high relolution ultrasound scanner and monitored by serial serum β HCG assay
EXPECTANT TREATMENT
Identification criteria (Ylostalo et al, 1993): - Falling level of serum β HCG at 2 day intervals - No sign of intrauterine pregnancy - Diameter of ectopic pregnancy <4 cm - No sign of rupture or of acute bleeding by TVS If any deviation from the above criteria
EXPECTANT TREATMENT
Spontaneous resolution occurs in 72%, while 28% will need laparoscopic salpingostomy In spontaneous resolution, it may take 4 – 67 days (mean 20 days) for the serum HCG to return to non pregnant level. The percentage fall in serum HCG by day 7 is a better indicator than the percentage fall by day 2. Warning:- Tubal pregnancies have been known to rupture when when serum HCG levels are low.
SUMMARY – KEY POINTS
Incidence of ectopic pregnancy is rising while maternal mortality from it is falling. Early diagnosis is the key to less invasive treatment. The choice today is Laparoscopic treatment of unruptured ectopic pregnancy. The trend is towards conservative treatment. Careful monitoring and proper councelling of patients is mandatory. Ruptured ectopics should be unususal with compliant patients and appropriate medical care.
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